Physical Activity and Pandemics: Lessons Learned from COVID-19 9819918014, 9789819918010

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Physical Activity and Pandemics Lessons Learned from COVID-19 Maryam Selk-Ghaffari Amirhossein Memari Behnaz Mahdaviani Ramin Kordi Editors

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Physical Activity and Pandemics

Maryam Selk-Ghaffari Amirhossein Memari Behnaz Mahdaviani  •  Ramin Kordi Editors

Physical Activity and Pandemics Lessons Learned from COVID-19

Editors Maryam Selk-Ghaffari Sports Medicine Research Center Neuroscience Institute Tehran University of Medical Sciences Tehran, Iran

Amirhossein Memari Sports Medicine Research Center Neuroscience Institute Tehran University of Medical Sciences Tehran, Iran

Behnaz Mahdaviani Sports Medicine Research Center Neuroscience Institute Tehran University of Medical Sciences Tehran, Iran

Ramin Kordi Sports Medicine Research Center Neuroscience Institute Tehran University of Medical Sciences Tehran, Iran

ISBN 978-981-99-1801-0    ISBN 978-981-99-1802-7 (eBook) https://doi.org/10.1007/978-981-99-1802-7 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore

Introduction

The pandemic of COVID-19 has led to economic and social consequences but also public health crisis via affecting populations’ lifestyles. Due to the social distancing strategies, physical inactivity has increased in various societies. This may lead to an increase in the burden of non-communicable diseases in long term, while we are aware of a wide range of benefits of physical activity including physical, psychological, and social dimensions. Furthermore, the other concerns are about the possible effects of physical inactivity on the course of COVID-19 infection, the severity of symptoms, mortality, or the complications of COVID-19. This book provides a comprehensive review of the current evidence regarding physical activity and COVID-19. The book ends with a suggested physical activity plan in future pandemics. Chapter 1 presents the trend of physical inactivity during COVID-19 pandemic among children, adolescents, adults, older adults, and in people with chronic complications. This chapter also provides a brief information regarding prevalence of physical inactivity after the COVID-19 pandemic. Chapter 2 discusses the physical activity as a protection factor of COVID-19 infection. This will answer the questions and clarify if physical activity was protective or not against COVID-19 infection in the COVID-19 pandemic. Chapter 3 discusses the importance of lifestyle and environmental exposures such as diet, smoking, sun exposure, stress, sleep, circadian rhythms, etc., in the prevention of infectious diseases such as COVID-19. Chapter 4 provides information regarding the role of engaging in regular physical activity in the prevention or inducing the severe form of the COVID-19 disease, ICU admission, hospitalization, and mortality. Indeed, this chapter will guide the practitioners how to recommend individuals to engage in physical activity during COVID-19. Chapter 5 discusses the boosting effect of physical activity on COVID-19 vaccines. Chapter 6 provides information regarding physical therapy methods in COVID-19 rehabilitation. Samples of comprehensive exercise programs including breathing, aerobic, and strength exercises are provided in this chapter. Finally, Chap. 7 proposes a social-­ecological model of the physical activity and discusses a modified action plan for enhancing physical activity level in the COVID-19 pandemic according to WHO’s global action plan for physical activity. You can either read the book from start to end or jump directly to the chapter that interests you. This book has gathered researchers from different regions and continents to share different viewpoints regarding physical activity and COVID-19. This v

Introduction

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book is for individuals trying to know more about the benefits of physical activity in pandemics (i.e. COVID-19) including public health experts and physicians. The book may be used by the practitioners in the recovery plans after a course of COVID-19 and related infections. In addition, the book can be applied as a reference to encourage policy makers developing physical activity action plans in pandemics. Sports Medicine Research Center Neuroscience Institute Tehran University of Medical Sciences Tehran, Iran   

Maryam Selk-Ghaffari [email protected] Amirhossein Memari [email protected] Behnaz Mahdaviani Ramin Kordi [email protected]

Acknowledgements

We acknowledge professor Robert Sallis and British Journal of Sports Medicine for their permission to re-use their findings and Dr Monir Shayestehfar for assisting us in the process of preparation of this book.

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Contents

1 COVID-19  and the Prevalence of Physical Inactivity��������������������  1 Sadegh Mazaheri-Tehrani and Roya Kelishadi 2 Physical  Activity as a Protective Factor of COVID-19 ������������������  9 Ana Carbonell-Baeza, Javier S. Morales, José Losa-­Reyna, Laura Martínez-Sánchez, Sonia Ortega-Gómez, Verónica Mihaiescu-Ion, Ivan Hoditx Martín-Costa, Marta Baena-Aguilera, Eduardo García-Rodríguez, Vanesa España-­Romero, Juan Luis Sánchez-Sánchez, and David Jiménez-Pavón 3 The  Importance of Lifestyle and Environmental Exposures on COVID-19 ������������������������������������������������������������������ 31 Javier S. Morales, Pedro L. Valenzuela, José Losa-­Reyna, Laura Martínez-Sánchez, Juan Luis Sánchez-Sánchez, Verónica Mihaiescu-Ion, Ivan Hoditx Martín-Costa, Sonia Ortega-Gómez, Marta Baena-Aguilera, Eduardo García-Rodríguez, Vanesa España-­Romero, Ana Carbonell-Baeza, and David Jiménez-Pavón 4 Physical  Activity and COVID-19 Severity and Mortality�������������� 49 Maryam Abolhasani 5 Physical Activity and COVID-19 Vaccines�������������������������������������� 57 Amin Gasmi, Amine Nehaoua, Sadaf Noor, Pavan Mujawdiya, and David Bilstrom 6 Post-COVID-19 Physical Rehabilitation������������������������������������������ 71 Juan Manuel Díaz, Silvia Denise Ponce-Campos, Nidia Rodriguez-Plascencia, and Amirhossein Memari 7 Strategies  for Enhancing Physical Activity in COVID-19 Pandemic ������������������������������������������������������������������������ 83 Alireza Hosseini Khezri and Mohammad Hosein Pourgharib Shahi

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1

COVID-19 and the Prevalence of Physical Inactivity Sadegh Mazaheri-Tehrani and Roya Kelishadi

1.1 Introduction Since December 2019, the world has faced a global health crisis caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), named COVID-19. SARS-CoV-2 is rapidly widespread all over the world and infected millions of people. Since there was no exact treatment for COVID-19, social distancing and health protocol compliance together was the best way to prevent its fast spread. Thus, governments started general lockdowns. Most of the citizens had to remain at home and work remotely. Almost all public places such as gyms, swimming pools, shopping malls, parks, schools, and universities were closed, and people just for essential activities (preparing food, buying medicine, medical care, and similar) could go out [1, 2]. These circumstances faced the world with great challenges in human lifestyle. Thus, it seemed logical to expect a significant reduction in individual physical activity (PA) and a significant increase in sedentary behaviors (SBs), during the COVID-19 pandemic, which could negatively affect global health [3]. According to

S. Mazaheri-Tehrani · R. Kelishadi (*) Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-Communicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran e-mail: [email protected]

the World Health Organization (WHO), PA is defined as all kinds of body movements by skeletal muscles, requiring energy expenditure such as walking, sports, cycling, and climbing stairs [4]. On the other hand, SBs involve activities with very low energy expenditure that are mostly performed sitting or lying down such as mobile phone (MP) use, computer use, TV watching, video gaming, and prolonged sitting position [5]. Comparison of the PA and SB levels before and during COVID-19 lockdown in most of the studies in this field indicated a reduction in PA levels and an increase in SBs among all populations, except in patients with eating disorders [6]. Physical inactivity and SBs are major causes of morbidity and mortality, during the last decades [7]. Different health complications such as diabetes mellitus, cardiovascular diseases, and neurological disorders are reported to be associated with higher physical inactivity and sedentary behavior [8]. Here, we are going to discuss changes in PA during the COVID-19 era in various regions of the world.

1.1.1 Physical Activity Changes Among Adults WHO recommends that adults (18–65 years old) should have at least 150  min of moderate-­ intensity aerobic PA (MIPA), or 75 min of vigorous ­intensity PA (VIPA), per week (Fig. 1.1) [4].

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 M. Selk-Ghaffari et al. (eds.), Physical Activity and Pandemics, https://doi.org/10.1007/978-981-99-1802-7_1

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S. Mazaheri-Tehrani and R. Kelishadi

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Children and Adolescents

Adults (ages 18 - 64 years) Older Adults (65 years and older) and paents with chronic complicaons

Moderate to vigorous intensity PA, at least 60 min per day during a week VIPA, at least three days per week

At least 150-300 min of MIPA or 75-150 min of VIPA or a combination during a week Muscle-strengthening exercises two times or more per week

At least 150-300 min of MIPA or 75-150 min of VIPA or a combination during a week Muscle-strengthening exercises two times or more per week Functional balance and strength exercises three or more times per week

Fig. 1.1  Strong recommendations for PA for different populations according to the WHO 2020 guidelines for PA

There are differences in length, and strictness of restrictions between countries [9]. Moreover, the attitudes and adherence of societies to restrictions are different [10]. Therefore, outdoor activities and consequently PA levels may differ among countries. Based on a cross-sectional survey in 11 countries, more than 40% of participants in 9 countries (Bulgaria, Brazil, China, India, Malaysia, North Macedonia, Turkey, Spain, and the United States) reported a reduction in PA during confinement. Moreover, compared to the results of the worldwide PA levels in 2016 [11], seven countries indicated higher prevalence of insufficient PA during COVID-19 lockdown [12]. These findings support the association between more stringent restrictions during lockdowns with higher physical inactivity levels, due to limited access of individuals to places such as fitness centers and gyms. Some other studies have been conducted regarding the changes in PA levels and SBs before and during the COVID-19 lockdown, and revealed similar results [13, 14]. Several studies are conducted on changes in PA levels in different populations, especially among students [15] and employees [16], which showed findings similar to the general population. Such attention to these populations might be due to greater changes in the lifestyles of students

and employees compared to other populations during COVID-19 restrictions. Students and most of the workers and staff should study and work online, and remotely, which dramatically reduced their daily outdoor activities. Most studies revealed similar reductions in PA levels among both genders [17], but some others indicated gender as an effector of PA levels [18, 19]. This mainly depends on the baseline physical exercise level of the participants.

1.1.2 Physical Activity Changes Among Children and Adolescents According to the WHO 2020 guidelines on PA, children and adolescents are recommended to do at least an average of 60  min of PA per day (Fig. 1.1) [4]. COVID-19 restrictions negatively affected children’s PA levels. Studies demonstrated a decrease ranging between 10.8 and 91  min per day in PA of children. Children of higher age, and lower socioeconomic status showed a greater reduction in the PA levels. COVID-19 has worsened the worldwide trend of inactivity in children [20]. The reduction in PA was less reported in girls, and children who lived in rural areas, in

1  COVID-19 and the Prevalence of Physical Inactivity

big houses, and with a higher number of family members [21]. Findings of a longitudinal study in 14 countries suggested that in addition to the strictness of restrictions of confinement, the environmental conditions as well as the level of stress in parents affected the PA levels in children aged under 5 years. During the COVID-19 lockdown, SBs and PA levels of children living in low and middle-­income countries are affected less than those in high-income countries. Moreover, higher levels of stress among parents are associated with lower PA levels among children [22]. However, another survey of 6–18 year-old children living in ten European countries did not indicate any association between PA level and the status of restrictions [23]. A cross-sectional survey among children and adolescents in nine European countries, suggested that about 25% of participants were less active during the winter lockdown (January and February 2021) compared to the spring 2020 lockdown. Thus, policymakers and families should make effort to promote an adequate level of physical activity for children, in order to avoid these changes in lifestyle behavior from becoming permanent [24]. PA levels and SBs in children are reported to be associated with PA and SBs in their parents, thus public health messages should also target parental lifestyle as a determinator of children’s lifestyle [25]. An investigation among students in Saudi Arabia demonstrated that participants had good knowledge and attitude toward the benefits of PA, but their PA levels were lower than recommended levels. Thus, more efforts are needed to provide opportunities for sufficient PA levels and change the behavior toward it [26].

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the country of origin. However, most of the included studies were conducted in Asian and European countries. At that time both continents were suffering from high rates of COVID-19, and countries in both continents made strict restrictions against the pandemic [27]. On the other hand, a systematic review of studies with participants older than 50 years found heterogeneous changes in the PA levels and suggested that pre-­ pandemic lifestyle affected lockdown-induced PA changes [28]. There are several reported benefits of physical exercise for older adults. Elderly people with higher PA levels have a lower risk for different non-communicable diseases. Besides, physically active elderly people experience a better quality of life. Therefore, encouraging the elderly to participate in physical exercises based on the WHO recommendations as mentioned before, is of great importance [29].

1.1.4 Physical Activity Changes in People with Chronic Complications

Chronic diseases (CDs) are prolonged diseases, generally with slow progression which may be associated with other health complications. The treatments of CDs are mainly summarized in avoiding risk factors, and physiological support, and unfortunately, a permanent cure is very rare [30]. Current evidence suggests that physical exercises may be an effective solution for several CDs such as cancers, diabetes, hypertension, chronic respiratory diseases, and heart failure by delaying the disease progression [31]. According to the WHO guidelines for PA, adults suffering from chronic complications should do at least 1.1.3 Physical Activity Changes 150 min per week of moderate-intensity aerobic Among Older Adults PA, 75 min per week of vigorous-intensity aerobic PA (VIPA), or a combination of both Older adults (65 years and older) are recom- (Fig. 1.1) [4]. mended to do at least 150  min of moderate-­ Several studies have been conducted on PA intensity aerobic PA, or 75 min of high-intensity changes in people with CDs, in order to find out PA, per week (the same as adults) (Fig. 1.1) [4]. the effect of restrictions on the healthy behaviors Results of a systematic review of 25 studies of individuals. A significant decrease in PA levels indicated a significant reduction in PA levels was observed, regardless of age, but the reduction among adults older than 60 years, regardless of in PA levels was higher among females [32].

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According to a meta-analysis of people with and without CDs, a significant decrease in step counts and duration of physical exercise on one hand, and on the other hand, a significant increase in sedentary time in both groups were observed. Changes in PA levels in both groups were mainly influenced by the strictness of restrictions [33]. The impact of COVID-19 lockdowns on PA of individuals with CDs should be considered for developing rehabilitation programs, otherwise, its negative consequences will affect the patient’s quality of life.

1.2 Health Complications of Physical Inactivity Due to COVID-19 Restrictions PA is reported to play a pivotal role in the prevention and management of several mental and psychological disorders, such as depression, anxiety, and stress (Fig.  1.2) [34]. Studies suggested an inverse association between PA levels and developing mental disorders during the pandemic. Individuals with a certain amount of PA have a lower risk of depression, anxiety, and emotional and sleep disorders [35, 36]. However, there is no consensus on the optimal amount, frequency, and

S. Mazaheri-Tehrani and R. Kelishadi

type of PA for preventing mental complications [37]. Longitudinal studies on adults and adolescents indicated that participants with higher levels of PA during and after COVID-19 restrictions, had better mental health and well-being [38, 39]. During the pandemic, musculoskeletal pains were one of the most reported health complications among students and employees. Due to sudden changes in work and study culture, most of the students and workers had to do their activities using computers, during the homestay. Studies suggested an association between physical inactivity and musculoskeletal pains [40–42]. Moreover, research showed that physical activity intervention significantly diminished the musculoskeletal pains of university students during confinement [43]. Physical inactivity is a key factor in developing various non-communicable diseases such as diabetes mellitus, cardiovascular diseases, metabolic syndrome, and hypertension. Changes in human lifestyle during the COVID-19 pandemic, made them more sedentary, and physically inactive, thus people should do enough PA (as mentioned before based on their age, and health condition), to prevent negative health consequences of confinement [44]. A big data analysis among Iranian children demonstrated more than half of them became overweight during the pandemic, and this is a serious threat to future health complications [45]. Because childhood obesity mostly remained during adulthood and may lead to several noncommunicable diseases [46]. There is limited data on the long-term effects of COVID-19 pandemic. More prospective investigations among different populations are needed to better clarify these long-term effects. However, the pivotal role of health care systems in promoting sufficient PA among populations, might prevent possible further adverse effects.

1.3 Physical Activity After the COVID-19 Pandemic

Fig. 1.2  Reported health complications of physical inactivity due to COVID-19 restrictions

Few studies have evaluated the PA levels after the COVID-19 lockdowns and reported heterogenous results. A longitudinal survey among people

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1  COVID-19 and the Prevalence of Physical Inactivity Table 1.1  Summary of studies assessing the PA levels after COVID-19 restrictions Author, date Schöttl et al. 2022 [47]

Country Alpine regions

Participants Adults

Massar et al. 2022 [48] Salway et al. 2022 [49]

Singapore

Adults

England

Adults and their children

ten Velde et al. 2021 [50] Faulkner et al. 2022 [38]

The Netherlands New Zealand and England

Children and adolescents Adults

Cocca et al. 2021 [51] AL-Mhanna et al. 2022 [52] Lu et al. 2022 [53]

Austria

Adolescents Adults

USA

Adults

Outcome Although there is a significant decrease in PA levels during lockdowns, most of the participants returned to their baseline PA levels after lockdowns Increase in PA levels after lockdowns compared to during confinement No significant change in the PA levels of parents, but there was a reduction in children’s PA comparing the levels after (May–December 2021) and before (March 2017–May 2018) lockdowns PA levels were still low after reopening schools compared to PA levels before the restrictions There is a significant decrease in PA levels during lockdowns, but there is no difference between PA levels during and after confinements There is an increase in PA levels after restrictions ease There is a significant increase in PA levels after the confinements PA levels decreased during the first weeks of restrictions and increased slowly during and after the lockdown, but did not return to the baseline levels before the restrictions

in Alpine regions, where there were severe restrictions during confinements, demonstrated a significantly lower PA during the first (March and April) and second (November and December) lockdowns, compared to the reopening period (May and October) in 2020. Most of the participants returned to the pre-pandemic level of PA [47]. Another study in Singapore indicated an increase in PA levels during the reopening period (September 2020) in comparison to the initial lockdown (April and May 2020) [48]. A study in the UK was used to evaluate the PA levels before (March 2017–May 2018) and after the COVID-­19 era (May–December 2021), among children and their parents. Their results indicated no significant change in PA levels of parents, but there was a reduction in children’s PA [49]. Based on mentioned studies, post-pandemic PA levels depends on different variables, such as the baseline PA levels, age, gender, socioeconomic status, and strictness of restrictions during the lockdown. Table  1.1 shows a summary of investigations on PA levels after confinements. And anyway, as physical inactivity had become a health issue even before the pandemic, and COVID-19 restrictions have worsened it, an

urgent need for maintaining the suggested levels of physical exercise is required [54].

1.4 Conclusion PA influences different aspects of human health; thus, it should be considered as a therapeutic action, not just an unstructured suggestion. Moreover, the world had faced physical inactivity as a health crisis during the last decades, and COVID-19 restrictions have worsened it. Therefore, it is important to maintain enough PA after the pandemic era and governments should prepare appropriate rehabilitation programs. Although those catastrophic days of the COVID-­19 pandemic are over, but if the harmful effects of it on the human lifestyle are not modified, its negative consequences will appear soon.

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7 39. Kaltschik S, Pieh C, Dale R, et al. Assessment of the long-term mental health effects on Austrian students after COVID-19 restrictions. Int J Environ Res Public Health. 2022;19:13110. https://doi.org/10.3390/ ijerph192013110. 40. Ghasemi S, Naghiloo Z, Soleimani RM.  Effect of virtual education conditions on musculoskeletal status and physical activity of university professors during the corona pandemic. Sci J Rehabil Med. 2021;10(1):175–85. 41. Patel N, Sheth M.  Comparison of musculoskeletal disorders in school going children before and after COVID-19. Int J Health Sci Res. 2021;11:67–73. 42. Roggio F, Trovato B, Ravalli S, Di Rosa M, Maugeri G, Bianco A, et al. One year of COVID-19 pandemic in Italy: effect of sedentary behavior on physical activity levels and musculoskeletal pain among university students. Int J Environ Res Public Health. 2021;18(16):8680. 43. Jain R, Verma V, Rana KB, Meena ML.  Effect of physical activity intervention on the musculoskeletal health of university student computer users during homestay. Int J Occup Saf Ergon. 2021;29(1): 1–6. 44. Polero P, Rebollo-Seco C, Adsuar JC, Pérez-Gómez J, Rojo-Ramos J, Manzano-Redondo F, et al. Physical activity recommendations during COVID-19: narrative review. Int J Environ Res Public Health. 2021;18(1):65. 45. Bagherian S, Ghasempoor K, Baker JS, Mashhadi M.  Physical activity behaviors and overweight status among Iranian school-aged students during the COVID-19 pandemic: a big data analysis. Iran J Public Health. 2022;51(3):676–85. 46. Kelishadi R, Heidari-Beni M. Prevention and control of childhood obesity: the backbone in prevention of non communicable disease. In: Kelishadi R, editor. Primordial prevention of non communicable disease. Cham: Springer International Publishing; 2019 [cited 2022 Aug 31]. p.  61–6. (Advances in experimental medicine and biology). Available from: https://doi. org/10.1007/978-­3-­030-­10616-­4_7 47. Schöttl SE, Schnitzer M, Savoia L, Kopp M. Physical activity behavior during and after COVID-19 stay-at-­ home orders—a longitudinal study in the Austrian, German, and Italian Alps. Front Public Health. 2022 [cited 2022 Aug 23];10. Available from: https://www. frontiersin.org/articles/10.3389/fpubh.2022.901763 48. Massar SAA, Ng ASC, Soon CS, Ong JL, Chua XY, Chee NIYN, et  al. Reopening after lockdown: the influence of working-from-home and digital device use on sleep, physical activity, and wellbeing following COVID-19 lockdown and reopening. Sleep. 2022;45(1):zsab250. 49. Salway R, Foster C, de Vocht F, Tibbitts B, Emm-­ Collison L, House D, et al. Accelerometer-measured physical activity and sedentary time among children and their parents in the UK before and after COVID-­19 lockdowns: a natural experiment. Int J Behav Nutr Phys Act. 2022;19(1):51.

8 50. Ten Velde G, Lubrecht J, Arayess L, van Loo C, Hesselink M, Reijnders D, Vreugdenhil A.  Physical activity behaviour and screen time in Dutch children during the COVID-19 pandemic: pre-, during-and post-school closures. Pediatr Obes. 2021;16:e12779. 51. Cocca A, Greier K, Drenowatz C, Ruedl G.  Relationship between objectively and subjectively measured physical activity in adolescents during and after COVID-19 restrictions. Behav Sci. 2021;11(12):177.53. 52. Al-Mhanna SB, Ghazali WS, Mohamed M, Sheikh AM, Tabnjh AK, Afolabi H, Mutalub YB, Adeoye AO, Nur MM, Aldhahi MI.  Evaluation of physical activity among undergraduate students in Mogadishu

S. Mazaheri-Tehrani and R. Kelishadi Universities in the aftermath of COVID-19 restrictions. PeerJ. 2022;10:e14131. 53. Lu Y, Jones PW, Murugiah K, Caraballo C, Massey DS, Mahajan S, Ahmed R, Bader EM, Krumholz HM.  Physical activity among patients with intracardiac remote monitoring devices before, during, and after covid-19–related restrictions. J Am Coll Cardiol. 2022;79(3):309–10. 54. Amini H, Habibi S, Islamoglu AH, Isanejad E, Uz C, Daniyari H.  COVID-19 pandemic-induced physical inactivity: the necessity of updating the Global Action Plan on Physical Activity 2018–2030. Environ Health Prev Med. 2021;26(1):32.

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Physical Activity as a Protective Factor of COVID-19 Ana Carbonell-Baeza, Javier S. Morales, José Losa-­Reyna, Laura Martínez-Sánchez, Sonia Ortega-Gómez, Verónica Mihaiescu-Ion, Ivan Hoditx Martín-Costa, Marta Baena-Aguilera, Eduardo García-Rodríguez, Vanesa España-­Romero, Juan Luis Sánchez-Sánchez, and David Jiménez-Pavón

2.1 Introduction Physical activity is the main factor for the prevention of numerous noncommunicable diseases [1] and provider of lower risks of all-cause mortality [2–4], but it has also been suggested to be a proA. Carbonell-Baeza · J. S. Morales · J. Losa-Reyna L. Martínez-Sánchez · S. Ortega-Gómez V. Mihaiescu-Ion · I. H. Martín-Costa M. Baena-Aguilera · E. García-­Rodríguez V. España-Romero MOVE-IT Research Group, Department of Physical Education, Faculty of Education Sciences and Biomedical Research Innovation Institute of Cádiz, University of Cádiz, Cádiz, Spain J. L. Sánchez-Sánchez MOVE-IT Research Group, Department of Physical Education, Faculty of Education Sciences and Biomedical Research Innovation Institute of Cádiz, University of Cádiz, Cádiz, Spain Health Sciences Department, Public University of Navarre, Pamplona, Spain D. Jiménez-Pavón (*) MOVE-IT Research Group, Department of Physical Education, Faculty of Education Sciences and Biomedical Research Innovation Institute of Cádiz, University of Cádiz, Cádiz, Spain CIBER of Frailty and Healthy Aging (CIBERFES), Madrid, Spain e-mail: [email protected]

tective behavior against coronavirus disease 2019 (COVID-19). In particular, it has been shown that the general population can gain substantial lifelong benefits by becoming physically active, independently of previous physical activity levels or established risk factors. Thus, regular physical activity, even from adulthood onward, can have a major impact on the health of the population [3]. Regarding the dose-response associations between physical activity, sedentary time, and allcause mortality, it has been reported that higher levels of total physical activity (at any intensity), and less time spent sedentary, are associated with significantly reduced risk for premature mortality. Therefore, it seems that there is evidence of a nonlinear dose response for the benefits of physical activity [2]. In addition, engagement in physical activities according to the recommendations, including both leisure aerobic and musclestrengthening activities, have been found associated with critical survival benefits [1]. However, despite the evidence regarding the benefits of physical activity, it was reported that 31% (ranged 17–43%) of adults are physically inactive worldwide, and 80% of 13–15 year olds do fewer than 60 min of physical activity of moderate to vigorous intensity per day while their inactivity raises by the age [5]. In fact, nowadays,

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 M. Selk-Ghaffari et al. (eds.), Physical Activity and Pandemics, https://doi.org/10.1007/978-981-99-1802-7_2

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the total direct cost of inaction on physical inactivity to public healthcare systems has been estimated to reach about $50 billion per year in the near future [6]. Many noncommunicable diseases (diabetes, cardiovascular diseases, cancer, etc.) have been found to be related to the increase in the risk/severity of COVID-19. In other words, the overall health of the population is at high risk from any pandemic in general, and in particular from pandemics affecting the immune system, the respiratory system, and comorbidities, such as COVID-19. In general, lower respiratory tract infections and pneumonia account for more than four million deaths annually [7]. These infections are caused by a combination of viral and bacterial pathogens that can be very contagious and spread rapidly leading to epidemics and pandemics as in COVID19. Consequently, among the numerous public health strategies to cope with pandemics [8], there was an especially relevant approach to resist COVID-19 outbreak including “stay at home” (lockdown) and reducing social contact with other people. However, certainly, the lockdown could impose very negative consequences on the population’s health [9]. Thus, many governments highlighted the importance of remaining physically active for health and well-being [10], advising individuals to do home-based physical activity. In this sense, physical activity may also have important functions in a pandemic and in the prevention of infectious diseases. In fact, it has been suggested that physically active people are likely to be more resilient to infection through better immune surveillance against pathogens [11]. In addition, based on the knowledge that severe infections are more likely in people with poorer cardiovascular and metabolic health and with preexisting chronic conditions, physical activity also was expected to have a protective effect against infectious disease by improving cardiovascular and metabolic health and lowering the risk of chronic diseases [12, 13]. Finally, it has

A. Carbonell-Baeza et al.

been suggested that physical activity is also associated with an enhanced response to vaccination [12]; which means active populations have improved immunity. In this sense, part of the scientific evidence underlines the utility of physical activity for resilience against COVID-19 [12, 14–16]. There are robust evidences in the support of physical activity and its beneficial influence on immunity [11]. In the past several narrative reviews, the role of physical activity on human immunity has been debated [11, 17], however, most of them were focused on the acute effect of exercises and centered on athletes. Moreover, some reviews evaluated the impact of exercise on the risk of self-­ reported upper respiratory tract infection, however, these were inconclusive due to a low level of evidence and very few available studies [18, 19]. However, in 2021, a systematic review and meta-analysis study [20] was conducted to evaluate the existing evidence of the effect of habitual physical activity on laboratory-assessed immune parameters, and the risk of community-­ acquired infectious diseases for the general population. For the first time, they provided very useful information about the effect of regular physical activity on immune system and infectious disease and consequently the pandemics, though the included studies were not specifically related to COVID-19. Therefore, there is a need to update the evidence regarding the role of physical activity on virus infections and immune system in case of COVID-­19. Thus, we should clarify the importance of engaging in regular physical activity for the general population which will help in developing new policies for future COVID-19 or similar virus outbreaks or even future pandemics. This will be crucial to help populations better fight this virus during a possible future wave, maximize responses to vaccination programs when available, and act as fast as possible (Fig. 2.1).

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Fig. 2.1  Overall overview of the synthesis of evidence regarding Physical activity as a protective factor against COVID-19

2.2 Evidences of Physical Activity Benefits Other than COVID-19 Pandemic The most updated systematic review and metaanalysis [20] was carried out in 2021 evaluating the evidence regarding the effect of habitual physical activity on laboratory-assessed immune parameters, and risk of community-­ acquired infectious disease for the general population based on objective markers. They conducted separate meta-analyses for each outcome of randomized controlled trials (RCTs) and observational studies when studies provided outcome data in comparable units or effect size that could be pooled. Authors stratified the analysis by population groups such as healthy adults, obese individuals, older adults (aged 60 years and over), and clinical populations particularly at risk of infectious diseases such as human immunodeficiency virus or HIV, organ transplant, and cancer patients. The relevance of this work can be understood considering 16,698 records revised in the

primary search, more than 600 full texts analyzed and the 55 studies finally included (7 observational prospective and 48 RCTs) [20]. The main conclusions were suggested to be extrapolated to community-acquired infectious diseases and infectious disease mortality like COVID-19.

2.2.1 Physical Activity and Community-Acquired Infectious Disease The analysis of observational studies showed a 31% risk reduction of community-­acquired infectious disease for those achieving the recommended levels of physical activity (150 min per week) or higher after considering a total sample of 557,487 individuals. Moreover, the risk of infectious disease mortality (mainly pneumonia) was also reduced by 37% for people achieving international recommendations (n  =  422,813 individuals) [20].

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2.2.2 Effect of Physical Activity Interventions on Immune System White Blood Cell Count The effect of moderate to vigorous intensity aerobic training (walking, running, or cycling) or a combination of aerobic and resistance training on total white blood cell was analyzed in 384 individuals from 10 studies [21–30]. The average duration was 15–120  min (median 30  min) and frequency of 3–5 times per week lasting from 4 to 26 weeks (median 12 weeks). The authors found there was no effect of physical activity interventions compared to control suggesting that moderate heterogeneity between studies could affect the finding [20]. Innate Immune System Cell Counts The effect of physical activity interventions on innate immune system cell count was also evaluated [20]. The intervention included moderate to vigorous intensity aerobic training [31–34] or a combination of aerobic and resistance training [27, 35] involving 15–120 min (median 45 min) of duration, frequency of 1–5 times per week (median 3), and lasting from 4 to 26 weeks (median 12 weeks). They found that physical activity interventions were effective to improve neutrophil count (n = 305 individuals) but not for monocytes or natural killer cells. Adaptive Immune System The efficacy of physical activity programs on total lymphocyte count was also studied including resistance training [36, 37], aerobic physical activity, and combination of resistance and aerobic (walking, cycling) physical activity [22, 23, 27]. The meta-analysis reported a significant effect of physical activity intervention on total lymphocyte count for healthy adults, but not in other groups or overall (n = 498 individuals) [20]. These interventions were moderate to vigorous intensity for a minimum of 30 min twice a week and lasted between 4 and 26 weeks (median 8 weeks).

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Furthermore, no significant effect of physical activity intervention was found for CD3+. In this case, physical activity interventions had a median frequency of 5 sessions per week, median duration of 40 min, lasting between 1 and 26 weeks (median 10 weeks) and involved aerobic activity, resistance training, and combination of aerobic and resistance modalities. Regarding T cell (CD4+), the meta-analysis showed that physical activity interventions are effective compared to control group in overall and the same for clinical populations [20]. The training parameters of these studies were a median frequency of 3 sessions per week, median duration of 40 min, lasting between 1 and 26 weeks (median 10 weeks), and involved aerobic activity, resistance training and combined aerobic and resistance activity at light to vigorous intensity. Although no significant effect of physical activity interventions was reported for CD8+ count, there was a statistically significant difference for clinical populations [20]. Median characteristics for the studies reporting on the CD8+ lymphocytes subpopulation were 3 sessions/week of 40 min for 8 weeks and involved resistance training, aerobic activity, or a combination of both. Immunoglobulins Chastin et al. [20] showed that physical activity interventions (median characteristics: 3 times per week, moderate to vigorous intensity, 30 min in length for 15 weeks) were effective on salivary IgA concentration overall, but not for serum IgA, IgG, or IgM. Vaccination In a systematic review of viral outbreaks other than COVID-19, only 6 studies were finally included as researching the effect of physical activity interventions on the outcomes of vaccination and reported differences in antibody titers for H1N1, H3N2, influenza type B, pneumococcal, and varicella zoster virus. The authors found a pooled relevant effect of these physical activity interventions for having higher antibody titers [20]. The median characteristics of the training

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Fig. 2.2  FITT parameters of physical activity interventions on immune system

program were 3 sessions per week of 60  min for 20 weeks prior to vaccination involving aerobic or combined aerobic and strengthening exercises. In summary, Chasten et  al. [20] suggest that physical activity interventions improved CD4 cell counts and salivary immunoglobulin IgA concentration and decreased neutrophil counts. Thus, a physical activity program promotes higher antibody concentration after vaccination (Fig. 2.2). Additionally, it should be considered that there are several factors, both modifiable and non-modifiable (such as age), that have been shown to influence vaccine-induced immune responses [38], and could therefore potentially influence the efficacy of COVID-19 vaccines. One of these is regular physical activity. It has been shown to modulate the immune response in studies on other vaccines such as influenza. A recent cross-sectional study has shown that elite athletes have an increased cellular (increased T cell) and antibody response after influenza vaccination [39]. These results could be particularly relevant if they were applicable to older people (those most vulnerable to infection). In fact, pre-

vious research shows that influenza vaccination may be less effective in older people (decreasing vaccine effectiveness from 52% in people aged 50–54 years to only 11% in people over 65 years) [40]. This reduction in vaccine effectiveness may be explained due a process known as immunosenescence (worsening of the immune system associated with aging, leading to an increased risk of infections) [41]. The evidence appears promising for the benefits of regular physical activity on the immune response to vaccination in the general population, particularly, in older people. In this regard, a systematic review including 20 studies (9 on the acute effect and 11 on the chronic effect of exercise interventions on vaccination responses) concluded that exposure to either acute (i.e., a single session) or regular exercise (repeated sessions) augments the immune response to vaccination, especially in older adults [42]. Therefore, it seems clear that the exercise performed near the time of immunization might be beneficial in improving the antibody response to vaccination. In this regard, several clinical trials have evaluated the immune response of a group

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of older people (>64 years) who were randomized to exercise for 10 months (3 weekly sessions of up to one hour of aerobic exercise) or to maintain their usual routine, being vaccinated against influenza both before and after the 10-month intervention [43, 44]. The results clearly showed that immune responses to the vaccine improved after participating in the exercise intervention. It is also important to mention that intensity appears to play a key role in the potential benefits of regular physical activity as a vaccine adjuvant. Thus, studies that have evaluated the acute effects of performing an aerobic exercise session at light intensity (45  min at 65 years) with COVID-19 Group allocation: (mean age ± SD)  – Exercise (IG): 69.4 ± 8 years  – Control group: 68.9 ± 7.6 years

Exercise/PA and control conditions Exercise: Respiratory exercises Control: No exercise

Intervention parameters (F.I.T.T.) Frequency: 2 days/week Intensity: Respiratory muscle training: 60% of max expiratory mouth pressure Time: Terminated when any of dyspnea, SpO2  85% was reached Type of Exercise: respiratory muscle training: 3 sets with 10 breaths in each set (handheld resistance device Threshold PEP) cough exercise: 3 sets of 10 active coughs diaphragmatic training: 30 maximal voluntary diaphragmatic contractions in the supine position, placing a medium weight (1–3 kg) on the anterior abdominal wall to resist diaphragmatic descent stretching exercise: move arm in flexion, horizontal extension, abduction, and external rotation home exercise: pursed-lip breathing and coughing (30 sets per day) Length: 6 weeks Outcomes Respiratory function: (FEV1, FVC and diffusing lung capacity for carbon monoxide) Cardiorespiratory and vascular fitness (6MWT, SpO2, heart rate, systolic blood pressure, diastolic blood pressure, respiratory rate, and perceived exertion Quality of life (SF36) Activities of daily living (ADL) (Functional Independence Measure) Mental status: self-rating anxiety scale (SAS) and self-rating depression scale (SDS)

(continued)

Main finding/conclusions After 6 weeks of respiratory rehabilitation in the IG, there disclosed significant differences in respiratory function and cardiorespiratory and vascular fitness In ADL, there was no significant improvement neither within the IG nor compared with the CG Quality of life was statistically significant within the IG and between the two groups Mental status in the IG decreased after the intervention, but only anxiety had significant statistical significance

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Study (year) McNarry et al. (2022) [73]

Design and sample RCT N = 148 (111 IG, 37 CG) Prior self-reported COVID-­19 infection with primary symptom of breathlessness (≥18 years) Group allocation: (mean age ± SD)  – Exercise (IG): 46.76 ± 12.03 years  – Control (CG): 46.13 ± 12.73 years

Table 2.1 (continued) Exercise/PA and control conditions Exercise: The PrO2TM a handheld inspiratory flow resistive device was used Control: Educational instructions at baseline

Intervention parameters (F.I.T.T.) Frequency: 3 days/week non-consecutive Intensity: Participants completed as many inspirations as they could prior to failure, defined as not achieving 80% SMIP on three consecutive breaths Time: 20 min Type of Exercise: Before each session, participants performed a maximal inspiratory effort from residual volume to determine sustained maximal inspiratory pressure (SMIP), with training subsequently requiring >80% SMIP to be maintained Each session involved up to six blocks of six inspirations, with the rest periods interspersing each inspiration progressively decreases from 40 to 10 s with each block Length: 8 weeks Outcomes Health-related quality of life (15-KBILD Questionnaire) Perceived breathlessness was assessed (Baseline Dyspnoea Index and Transition Dyspnoea Index) Inspiratory muscle strength (PrO2TM device)

Main finding/conclusions According to intention to treatment, there was no difference between groups in KBILD post-intervention, but IG improved in the KBILD subdomains of breathlessness and chest symptoms. Also improved respiratory muscle strength and estimated aerobic fitness

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Design and sample RCT N = 30 (15 for each group) Recent mild or moderate COVID-19 (no or low-grade fever; 37.5–38.3 oC) (25–45 years) Group allocation: (mean age ± SD)  – Exercise (EG): 44.6 ± 4.3 years  – Control (CG): 35.3 ± 3.9 years

RCT N = 378 (190 IG, 188 CG) Community dwelling adults, able to perform self-care, with a new SARS-CoV-2 infection (verified by reverse transcription polymerase chain reaction tests) and symptoms of COVID-19 Group allocation: (mean age ± SD)  – Exercise (IG): 46.7 ± 13.0 years  – Control (CG): 47.0 ± 13.3 years

Study (year) Mohamed and Alawna (2021) [59]

Mollerup et al. (2021) [68] Exercise: Positive expiratory pressure (PEP) flute self-care. PEP kit with resistors (yellow, size 2.5 mm; blue, 3.0 mm; green, 3.5 mm; Intersurgical, Berkshire, UK) Control: No exercise

Exercise/PA and control conditions Exercise: Walking/running on a treadmill or bicycling on a stationary bicycle Control and exercise groups: Standardized medications, including the Hydroxyclorocin Sulfate 200 Mg Film Tablet (Plaquenil 200 Mg Film Tablet), 2 times/day, 200 Mg/ time, for 5 days

Intervention parameters (F.I.T.T.) Frequency: 3 days Intensity: 60–75% of the predicted MHR (calculated as MHR = 210-age). 12–14 RPE Time: 40 min Type of Exercise: Aerobic training Length: 2 weeks Frequency: 3 times/day Intensity: NP Time: NP Type of Exercise: Breathing Exercises with PEP Length: 30 days Change in symptom severity (Self-reported chronic obstructive pulmonary disease assessment test) Self-reported urgent care visits due to COVID-19, number of COVID-19-­ related symptoms, and change in self-rated health

Outcomes Total lymphocytes, leukocytes, and monocytes Concentrations of IL-6, IL-10, and TNF-α Quality of life in respiratory diseases (Wisconsin Upper Respiratory Symptom Survey)

(continued)

IG improved self-reported severity of respiratory symptoms, compared to CG The average number of COVID-19-­related symptoms decreased to around 5, with no significant group difference. More participants in the IG reported urgent care visits than in the CG, but this group difference was not significant

Main finding/conclusions IG increased quality of life and Leukocytes, Lymphocytes, and Immunoglobulin-A compared with CG after the intervention Interleukin-6, Interleukin-10, and TNF-α showed nonsignificant differences between both groups

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Design and sample RCT N = 76 (38 for each group) Men with post-COVID-19 sarcopenia (60–80 years) Group allocation: (mean age ± SD)  – Low-intensity aerobic and strength training group (IG1): 63.2 ± 3.1 years  – High-intensity aerobic and strength training group (IG2): 64.1 ± 3.2 years

RCT N = 76 (38 for each group) Obese male children (5–12 years) Group allocation: (mean age ± SD)  – Exercise (IG): NP  – Control (CG): NP

Study (year) Nambi et al. (2022) [69]

Nambi et al. (2022) [64]

Table 2.1 (continued)

Exercise: High-intensity aerobic training with a high-protein diet Control: NP Regular physical activities and eating a regular diet

Exercise/PA and control conditions Exercise: Aerobic training exercises with treadmill and cycle ergometer Strength exercise: The major group muscles such as shoulder flexors, shoulder extensors, shoulder abductors, elbow flexors, elbow extensors, hip flexors, hip extensors, knee flexors, knee extensors, abdominal, and back muscles

Intervention parameters (F.I.T.T.) Frequency: 4 days/week Intensity: IG1: 40–60% of maximum heart rate IG2: 60–80% of maximum heart rate Both groups (strength): 10 RM* 3 sets with a rest period of 60 s Time: 90 min Type of Exercise: Aerobic and strength training Length: 8 weeks Frequency: 4 days/week Intensity: 50–70% MHR Time: 50 min Type of Exercise: Aerobic training and strength training Length: 8 weeks Main finding/conclusions IG1 improved handgrip strength, kinesiophobia status, and quality of life more than IG2 in post-­COVID-19 sarcopenia patients

After intervention, and at the end of follow-up, BMI, mid-arm CSA, mid-thigh CSA, mid-calf CSA, leptin, TNF-α, and IL-6 showed more improvement in IG than CG

Outcomes Muscular strength (handgrip strength) Muscle mass Kinesiophobia Quality of life (SarQol questionnaire)

Basal metabolic index (BMI) Muscle cross-sectional area (CSA) and biochemical markers

22 A. Carbonell-Baeza et al.

Design and sample RCT N = 52 (26 each group) Patients with dyspnoea at the Chest Diseases Clinic (>18 years) Group allocation: (mean age ± SD)  – Exercise (IG): NP  – Control (CG): NP

RCT N = 44 (22 each group) Adults hospitalized for COVID-19 with mild to moderate dyspnoea and no chronic diseases (>18 years) Group allocation: (mean age ± SD)  – Exercise (IG): 49.18 ± 13.50 years  – Control (CG): 54.09 ± 14.68 years

Study (year) Okan, Okan, and Duran-­ Yücesoy (2022) [65]

Öner-­ Cengiz, Ayhan and Güner (2022) [66] Exercise: Breathing exercise with Triflo Control: Routine medical treatment and care

Exercise/PA and control conditions Exercise: 10 breathing exercises Mild-intensity walking program of 20–30 min five times a week Control: 20–30 min light-intensity walk five times a week

Intervention parameters (F.I.T.T.) Frequency: Breathing exercises: 3 sessions/day Aerobic: 5 days/week Intensity: Fatigue score of  20% •  HRe:  120X′ • Signs of shock, arrhythmia or acute myocardial ischemia

Neurological conditions •  RASSf: 20 cmH2O •  Hyperactive delirium •  Coma •  Seizures

SaO2 Saturation of Oxygen RR Respiratory Rate c SBP Systemic Blood Pressure d MAP Mean Arterial Pressure e HR Heart Rate f RASS Richmond Agitation-Sedation Scale g ICP Intracranial Pressure a

b

tory, cardiovascular, and/or neurological conditions that could be a signal to stop (shown in Table  6.5). These conditions are related to

o­ xygen concentration, body temperature, respiratory and heart rate, blood pressure, and consciousness, among others [3].

6  Post-COVID-19 Physical Rehabilitation

6.3.2 Contraindications Due to the several complications and physiological dysregulation in patients’ condition, there are some exclusion criteria that must be considered to avoid a decompensation or complication event of the physical therapy. First, it is indispensable to avoid physical therapy treatment for patients in acute phase unless benefits will be greater. Second, it should exclude patients with some pathologies that may impede mobility; for example, resting patients with heart rates >120 bpm or with myocarditis, pericarditis, and pulmonary embolism [1]. Other contraindications are the course of thromboembolism, bacteremia, sepsis, and other active infection and other coexisting diseases that are not suitable for exercise [3].

6.3.3 Clinical Reassessment After completing physical therapy sessions and/ or in the middle of the plan, a medical reassessment evaluation is necessary to observe and evaluate the physical conditions and clinical progress compared to the first assessment. Although as part of the final or middle evaluation, it is essential to repeat at least the same test from the first time, it can be essential to consider more ­evaluation tests in final assessment to expand the tracing of extra conditions. These recommendations ensure the correct and reliable tracking of patient’s data to discharge or extend their treatment [19].

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stress); by decreasing considerably the severity of mental alterations. All the above changes have resulted in a considerable increase in patient quality of life due to the reintegration into their daily activities [1, 2, 20]. For hospitalized cases, it has been observed a reduction in hospital stay time and an improvement in muscular tone and reducing the effects of prolonged immobility syndrome as well as increasing the upper and lower airways conditions and values. These results are a fundamental part of improving intrahospital recovery, reducing the mortality rate, and decreasing the sequelae derived from the hospital stay [3, 12, 21]. Finally, it is noteworthy to mention that even in some cases where the quantitative values do not show a significant improvement, patients report a better quality of life and a reinstatement in daily activities. These findings and possible scenarios are an important point of analysis, research, and discussion for future studies of post-pandemic rehabilitation.

6.5 Conclusion

Data shows that physical and pulmonary rehabilitation is an essential multidisciplinary treatment for post-COVID-19 syndrome, ­ focused into improving the physical and psycho-emotional condition of the patients ­ which is affected by the multiple sequels of the disease. The essential aim of physical therapy is the re-establishment and reintegration of the patients into their daily activities. An accurate diagnosis of post-COVID-19 sequels is the first 6.4 Results step in this treatment method in order to screen the physical condition before beginning the After completing PT sessions, different studies physical therapy. However, the establishment of showed a considerable decrease in patients inclusion and exclusion criteria in each physisequalae, at least 50% in most cases. Also, an cal therapy unit is indispensable with the intenincrease in lung values (FVC, FEV, FEV1, MIP, tion of avoiding any undesired effects during and MEP), aerobic exercise capacity metabolic the treatment. Physical rehabilitation has the parameters, and physiological parameters (breath ability to restore the health condition of each and heart rate, blood oxygen saturation, and patient by improving physical fitness and blood pressure) were observed. Furthermore, removing the sequelae developed by this multidata showed an improvement in psycho-­ systemic disease in ambulatory and hospitalemotional conditions (depression, anxiety, and ized cases.

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10. Santus P, Tursi F, Croce G, Di Simone C, Frassanito F, Gaboardi P, Airoldi A, Pecis M, Negretto G, Radovanovic D.  Changes in quality of life and dyspnoea 1. Arbillaga-Etxarri A, Lista-Paz A, Alcaraz-Serrano after hospitalization in COVID-19 patients discharged V, Escudero-Romero R, Herrero-Cortina B, Balañá at home. Multidiscip Respir Med. 2020;15(1):713. Corberó A, Sebio-García R, Vilaró J, Gimeno-­ https://doi.org/10.4081/mrm.2020.713. Santos E.  Fisioterapia respiratoria post-COVID-19: 11. Eggmann S, Kindler A, Perren A, Ott N, Johannes algoritmo de decisión terapéutica [Respiratory physF, Vollenweider R, Balma T, Bennett C, Silva IN, iotherapy in post-COVID-19: a decision-­ making Jakob SM. Early physical therapist interventions for algorithm for clinical practice]. Open Respir patients with COVID-19 in the acute care hospital: a Arch. 2022;4(1):100139. https://doi.org/10.1016/j. case report series. Phys Ther. 2021;101(1):pzaa194. opresp.2021.100139. https://doi.org/10.1093/ptj/pzaa194. 2. Ponce-Campos S, Díaz J, Moreno-Agundis D, et  al. 12. Li L, Yu P, Yang M, Xie W, Huang L, He C, GosA physiotherapy treatment plan for post-COVID-19 selink R, Wei Q, Jones AY.  Physical therapist manpatients that improves the FEV1, FVC, and 6-min agement of COVID-19  in the intensive care unit: walk values, and reduces the sequelae in 12 sesthe West China Hospital experience. Phys Ther. sions. Front Rehabil Sci. 2022;3:907603. https://doi. 2021;101(1):pzaa198. https://doi.org/10.1093/ptj/ org/10.3389/fresc.2022.907603. pzaa198. 3. Jang MH, Shin MJ, Shin YB. Pulmonary and physi13. Kinoshita T, Nishimura Y, Umemoto Y, Fujita Y, Kouda cal rehabilitation in critically ill patients. Acute Crit K, Yasuoka Y, Miyamoto K, Kato S, Tajima F.  The Care. 2019;34(1):1–13. https://doi.org/10.4266/ effects of early rehabilitation in the intensive care unit acc.2019.00444. for patients with severe COVID-19 pneumonia: a ret4. Mahmoudi H, Saffari M, Movahedi M, Sanaeinasab rospective cohort study. J Clin Med. 2022;11(2):357. H, Rashidi-Jahan H, Pourgholami M, Poorebrahim https://doi.org/10.3390/jcm11020357. A, Barshan J, Ghiami M, Khoshmanesh S, Potenza 14. Vanhorebeek I, Latronico N, Van den Berghe MN.  A mediating role for mental health in associaG.  ICU-acquired weakness. Intensive Care Med. tions between COVID-19-related self-stigma, PTSD, 2020;46(4):637–53. https://doi.org/10.1007/s00134-­ quality of life, and insomnia among patients recovered 020-­05944-­4. from COVID-19. Brain Behav. 2021;11(5):e02138. 15. Farr E, Wolfe AR, Deshmukh S, et  al. Diaphragm https://doi.org/10.1002/brb3.2138. dysfunction in severe COVID-19 as determined by 5. 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7

Strategies for Enhancing Physical Activity in COVID-19 Pandemic Alireza Hosseini Khezri and Mohammad Hosein Pourgharib Shahi

7.1 Introduction Based on previous studies, physical inactivity leads to physical and mental disorders in children, adolescents, adults, and older populations [1]. During COVID-19 pandemic, most activities were banned due to pandemic control regulations in different regions [2]. These regulations involved social distancing, locking down public exercise facilities including gyms, outdoor sports activities, parks and playgrounds, and delaying sports matches in different countries. Simultaneously, the transportation domain of physical activity decreased during COVID-19 pandemic due to remote working regulations in various occupations. Consequently, studies have shown a decline in the level of physical activity in different regions during COVID-19 pandemic [3, 4]. In this chapter, we are trying to evaluate physical activity and its determinants based on socialecological model determinants; thus, we discuss the issue at individual, interpersonal, and envi-

A. H. Khezri (*) Department of Kinesiology, The University of North Carolina, Greensboro, NC, USA M. H. Pourgharib Shahi Sports Medicine Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran

ronmental levels. In this chapter, we provide strategies and solutions to increase physical activity level during the COVID-19 pandemic and similar situations.

7.1.1 Individual Level of Physical Activity The first level of any action plan related to the social-ecological model in physical activity is the individual level. The individual level consists of biological and personal factors such as age, ethnicity, sex, education level, physical fitness, and socio-economic status [5]. Strategies at the individual level aim to change the behavior, attitudes, and beliefs of physical activity [6]. Interestingly, individual factors are critical enhancing public health strategies, since variables such as economic status, education, and knowledge are linked and should be integrated into public health [7, 8]. Action plans aimed at an individualized level including behavioral change strategies should be considered to keep activating individuals. Individuals might face several restrictions during the pandemic, however, the individual factors could encourage them back to physical activity programs based on their health conditions [9]. For example, people who have been suffering from the COVID-19 disease might start to do regular low-intensity walking after training to

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 M. Selk-Ghaffari et al. (eds.), Physical Activity and Pandemics, https://doi.org/10.1007/978-981-99-1802-7_7

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begin their rehabilitation. To do so, the self-monitoring of health is the first step to examine if there is a risk related to their health condition during the pandemic. One recommended strategy to return to physical activity is the “Ask, Assess, Advise” approach. In this approach, the individual level is focused to promote the level of activity by discussing the level of their activity, assessing all required factors such as a personal goal to engage the person in physical activity, and advising enough information and knowledge [10]. Finally, increasing motivation and healthy habits should be targeted in physical activity action plans at the personal or individual level in social-ecological models. To do so, educators and educational system managers are recommended to create new innovative strategies. Age, sex, and family income are proposed as determinants of physical activity level during COVID-19 pandemic [11, 12]. Proposing affordable activities like walking, especially in low-income communities, might be another solution to increase the level of physical activity during pandemics.

7.1.2 The Interpersonal Level of Physical Activity Social interaction, community, and social support are known as interpersonal level, based on social-ecological model in physical activity strategies [5]. There is a big challenge in encouraging people to enhance their physical activity level by utilizing their social interaction [13]. Practically, healthy behavior is created from education, healthy environment, supporting policy, health-­enhancing interaction of individuals, and social support. A multisystem approach must be provided to promote physical activity levels in the long term. Effective social support and community interaction will strengthen the healthy behavior in an appropriate environment. For example, education would not be able to support changing behavioral strategies when other elements in the environment are not supportive [14].

A. H. Khezri and M. H. Pourgharib Shahi

Different variables of the interpersonal level are integrated into the overall health and health-­ promoting programs. For example, the communication (one aspect of the interpersonal level) related strategies and social media will provide the population regarding broad spectrum of benefits of physical activities and guide individuals on how to increase their level of physical activity. In case of a pandemic, restrictions could harm physical activity, though new strategies such as online exercises and online courses have been presented to enhance the activity level. The evidence shows that people spent most of their time on social media during lockdown, thus online education and online exercise programs are potential solutions to increase physical activity level in the pandemics. Surprisingly, a recent study shows that people have had more free time during the pandemic and they have established more physical activities such as walking near home, cycling, and running in the permitted area in the lockdown. Thus, we may hypothesize that people can find a way to enhance physical activity behavior during pandemic using the self-regulation strategies. In a very recent study, Parental Encouragement and Engagement in Physical Activity and Dog Ownership Confederated Healthy Movement were two types of strategies that people used to keep or enhance physical activity during lockdown. Moreover, the innovative strategies to increase the level of motivation, self-regulation, and playing in the open space area could be helpful to enhance physical activity in different ages. Findings show that the interpersonal and individual determinants can have a few positive effects on physical activity during the pandemic, however, educational based and government supports are mandatory to establish these promising effects. Thus, it is recommended that long-term programs must include different approaches of individual (self-regulation), environmental (facility and dynamic area for activity), educational (teaching and learning about the impact of physical activity in lifelong), and more innovative strategies such as online exercises to increase the chance of achievement.

7  Strategies for Enhancing Physical Activity in COVID-19 Pandemic

7.1.3 The Environmental Level of Physical Activity The social ecological models demonstrated the possible effect of the environment on physical activity levels. The environment may enhance active living by creating a mechanism to enhance opportunities and facilities for engaging in physical activity. Before the pandemic, environmental factors such as insufficient exercise facilities, increased use of the car, lack of physical education classes, and environmental safety were the most rated environmental barriers to physical activity in different age groups. There are connections between knowledge and the environment, as knowledge could be affected by different environmental conditions. Thus, there are important questions to be answered, including “Can environmental aspects improve the level of physical activity during the pandemics?” and “How these aspects could be increased during the COVID-19 pandemic?”. To date, studies have reported the effective role of changing environment in physical activity promotion [15]. Designing the appropriate environment according to all restrictions when we face pandemics is crucial (2). For example, initiative methods must be applied to encourage people to use stairs rather than using the escalator or lift, though the effect of this method could be transient. Indeed, changing the appearance and characteristics of the environment, even during a pandemic, might be worthwhile for physical activity strategies.

7.1.4 Governments One of the important parts of any action plan in enhancing physical activity during the pandemic is defined as governmental domain which is related to policies, management, economic status, and regulations on physical activity plans [15]. During COVID-19 pandemic, various regulations were developed by governments to decrease the spread of COVID-19. These regulations consisted of social distancing, banning public places, changing conditions for conducting

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sports matches, and home quarantine at the beginning of the COVID-19 pandemic [16]. Regardless of individual levels such as self-­ regulation and environmental aspects such as the facilities for indoor and outdoor activities, governmental policies at the beginning of the COVID-19 pandemic not only made a pause for physical activities but also made it difficult for people to keep their physical activity routines [16]. Policymakers and experts of sports organizations should collaborate to enhance physical activity in different populations during proposed restrictions and lockdowns to outweigh them. Understanding physical behavior habits and predicting physical activity change is essential for the systems to design an alternative approach when a crisis comes up to affect mental and health issues in society. As an example of the policy role for schools, Nam Kahyun et  al., explained a policy framework of relationship between physical education, physical activity in school, physical activity out of school, and family-staff physical activity level [17]. This framework entitled as Comprehensive School Physical Activity Program (CAPAP) model was designed to enhance the level of activity in school and out of school. Indeed, authorities or managers could use these models and frameworks in schools to make active life out of school.

7.2 Strategies to Promote the Level of Physical Activity During COVID-19 Pandemic The World health organization (WHO) proposed “Global action plan on physical activity 2018– 2030, more active people for a healthier world” (GAPPA) as a guild for developing physical activity action plans in different regions [15]. GAPPA provides a multisystem-based action plan including four main purposes. Developing active society, active environments, active people, and active systems are the main objectives of GAPPA which should be adapted according to the various condition including COVID-19 pandemic.

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A. H. Khezri and M. H. Pourgharib Shahi

Developing an active society consists of cultural standards, community beliefs, lifestyle based on improving knowledge, and behavioral change techniques. Broadcasting health information via social media regarding the role of physical activity in prevention and control of COVID-19 pandemic is recommended. Governmental health agencies should establish national physical activity campaigns to educate individuals regarding behavior change, conditions of engaging in physical activity, and benefits of physical activity during pandemics. Cognitive knowledge can develop a culture of physical activity among people, especially young people. Using diverse ways of teaching and learning such as “learning from each other” might promote knowledge about physical activities by using social interaction approach. In this strategy, people learn from each other, which would positively enhance the level of activity in the future. Currently, innovative educational approaches including online physical activities classes are being considered. The influence of social media in online education in exercise domain is significant. Professionals in public health and behavioral science should remedy applications for social media to share the benefit of physical activity and trend it by public health organizations. Based on active society objective in GAPPA following strategies are recommended:

ent target populations. The following strategies are proposed to increase physical activity during COVID-19 pandemic in active environments domain:

1. Developing social campaigns and initiations to broadcast benefits of physical activity against COVID-19 infection, severity, hospitalization, ICU admission, and mortality. 2. Applying virtual spaces to teach individuals how to keep active and engage in home-based exercises. 3. Educating exercise experts and physical activity coaches on how to teach individuals home-­ based exercises.

Creating active government consists of determining leadership, physical activity co-operator organizations, research systems, surveillance data systems, advocacy, and financial sources to increase physical activity. Governmental health agencies should establish national physical activity action plans, educational programs regarding behavior change, and guidelines for physical activity during pandemics.

Developing active environments consists of providing safe and accessible facilities to engage in physical activity programs. Determining the barriers and limitations of the environment for engaging in physical activity is mandated to promote the level of physical activity among differ-

1. Develop policies to improve walkable and cycling routes’ accessibility and safety. 2. Upgrading the walking and cycling infrastructure based on social distancing principles including increasing the routes and widening sidewalks. Developing active people consists of providing opportunities and improving accessibility of physical activity plans for individuals of different ages and with different physical fitness to engage in exercise programs. The following strategies are proposed: 1. Develop appropriate virtual physical education programs for individuals of any age with any physical condition. 2. Creating virtual rehabilitation centers for post-COVID-19 patients including cardiopulmonary rehabilitation. 3. Providing home-based individualized programs applying media programs for high-risk population including older population, disabled individuals, and individuals with chronic diseases.

1. Creating upgraded physical activity strategies during COVID-19 epidemic based on all protective principles including social distancing. 2. Upgrading physical activity level surveillance systems and evaluating barriers to physical activity during COVID-19 epidemic.

7  Strategies for Enhancing Physical Activity in COVID-19 Pandemic

3. Reinforcing advocacy system to improve awareness about the physical activity benefits in protection against infection and severity of the COVID-19 disease.

7.3 Conclusion Modification of physical activity action plans due to COVID-19 pandemic or similar conditions is mandated. Thus, it is recommended to design a modifiable lifelong framework via using multisystem approaches including individual, interpersonal, environmental domains, and governments. Based on social-ecological model, a multisystem approach enhances the overall physical activity level of individuals in all age groups and with any physical condition. Finally, virtual space and social media are significant promises to enhance physical activity action plans in critical conditions.

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